Urological Laparoendoscopic Single Site Surgery: Multi-Institutional Analysis of Risk Factors for Conversion and Postoperative Complications
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA. The Journal of urology
(Impact Factor: 4.47).
04/2012; 187(6):1989-94. DOI: 10.1016/j.juro.2012.01.062
We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery.
The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications.
Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications.
Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.
Available from: Aly M Abdel-Karim
- "None of our patients developed an incisional hernia at the port site. In our multi-institutional analysis of risk factors of conversion and postoperative complication in 1163 patients who had LESS for different indications, postoperative complication rate was low and this was comparable with that of conventional laparoscopy . Different studies have shown that LESS results in decreased length of hospital stay, decreased analgesic use and increased patient satisfaction [3e8]. "
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ABSTRACT: Although there are increasing reports in the literature about laparoendoscopic single-site surgery (LESS) as a tool for treatment of different pathologies in adults, the applications of LESS in pediatric urology are still limited. In this report we present the largest case series of LESS as an option for treatment of different urologic pathologies in pediatrics.
From January 2011 to June 2013, LESS was done for variable urologic pathologies in pediatrics. Indications of LESS included undescended testes, varicocele, nehrectomy for both non-functioning and multicystic dysplastic kidneys as well as pyeloplasty. Both R-port and Covedien port were used, and were inserted through a periumbilical skin incision. Whenever R-port was used, we used both pre-bent and straight instruments, whereas with Covedien port both articulating and straight instruments were used. Pyeloplasty was done through hands-free intracorporeal suturing using 4/0 vicryl. All procedures were done by a single experienced laparoscopist. Data were collected during and after surgery then analyzed retrospectively.
Twenty-two children with mean age of 6.3 ± 4.2 years had 39 LESS procedures. Thirteen patients had undescended testes (bilateral = 7, unilateral = 6, total = 20 undescended testes); 10 of them had primary orchiopexy, while nine had first stage Fowler-Stephens orchiopexy and these children subsequently had second stage Fowler-Stephens orchiopexy after 6 months and one child had orchiectomy. Four patients with varicocele (left = 3, bilateral = 1) had varicocelectomy. Two children had nephrectomy for both non-functioning hydronephrotic as well as multicystic dysplastic kidneys. Three children with ureteropelvic junction obstruction had LESS pyeloplasty, of whom two had dismembered pyeloplasty and one had non-dismembered Y-V plasty. There was no conversion to conventional laparoscopy, open surgery or adding an extra-port in any patient. Mean operative time was 89.6 ± 22.8 min. Mean blood loss was 32.2 ± 22.1 cc. No intraoperative or postoperative complications were reported. Mean hospital stay was 0.5 ± 0.6 days. Mean visual analog pain scale at discharge was 0.5 ± 0.3. Mean follow-up was 18.6 ± 6.4 months.
LESS is a feasible and safe option for treatment of different urologic pathologies in pediatrics. However, more patients, indications and prospective comparative studies are needed for further evaluation of the role of LESS in pediatric urology.
Copyright © 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Available from: PubMed Central
- "Therefore, we concluded that R-LESS PN in the current fashion should be offered only to selected patients with low complexity and small tumors. These results were also reported by other studies, whereas European association guidelines recommend that LESS PNs should be performed only as part of a clinical study [15,16]. This is logical, because it is admitted worldwide that the current Da Vinci system (Intuitive Surgical Inc.) is not designed to be used in this kind of procedure. "
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To report our initial clinical cases of robotic laparoendoscopic single-site (R-LESS) partial nephrectomy (PN) performed with the use of the novel Da Vinci R-LESS platform.
Materials and Methods
Three patients underwent R-LESS PN from November 2013 through February 2014. Perioperative and postoperative outcomes were collected and intraoperative difficulties were noted.
Operative time and estimated blood loss volume ranged between 100 and 110 minutes and between 50 and 500 mL, respectively. None of the patients was transfused. All cases were completed with the off-clamp technique, whereas one case required conversion to the conventional (multiport) approach because of difficulty in creating the appropriate scope for safe tumor resection. No major postoperative complications occurred, and all tumors were resected in safe margins. Length of hospital stay ranged between 3 and 7 days. The lack of EndoWrist movements, the external collisions, and the bed assistant's limited working space were noticed to be the main drawbacks of this surgical method.
Our initial experience with R-LESS PN with the novel Da Vinci platform shows that even though the procedure is feasible, it should be applied in only appropriately selected patients. However, further improvement is needed to overcome the existing limitations.
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